Provider Demographics
NPI:1508313982
Name:BEAN, DERESHA
Entity Type:Individual
Prefix:
First Name:DERESHA
Middle Name:
Last Name:BEAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7450 NORTHGATE DR
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70128-2326
Mailing Address - Country:US
Mailing Address - Phone:281-204-3624
Mailing Address - Fax:
Practice Address - Street 1:1615 POYDRAS ST
Practice Address - Street 2:STE. 902
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70112-1254
Practice Address - Country:US
Practice Address - Phone:504-648-6820
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-02
Last Update Date:2016-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1558649087Medicaid